Plastic surgeons can play a major role in diagnosing and treating this potentially fatal condition

Skin cancer is the most common form of cancer in the United States. More than 500,000 new cases are reported each year, and the incidence rate is rising faster than any other type of cancer. Whereas skin cancers can be found on any part of the body, about 80% appear on the face, head, and neck, where they can be disfiguring as well as dangerous.

The purpose of this article is to discuss the different types of skin cancer, their causes, and preventive measures that patients can take; and to help your practice benefit patients by diagnosing and treating skin cancer and other skin growths.

Who Gets Skin Cancer—and Why
The primary cause of skin cancer is UV radiation—most often from the sun, but also from artificial sources like sunlamps and tanning booths. In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and perhaps the thinning of the earth’s protective ozone layer are behind the alarming rise we are now seeing in the skin-cancer rate.

Anyone can get skin cancer, regardless of his or her skin type, race, age, geographical location, or occupation. But the risk is greater if

• the patient’s skin is fair and freckles easily;
• the patient has light-colored hair and eyes;
• the patient has a large number of moles, or moles of unusual size or shape;
• the patient has a family history of skin cancer or a personal history of blistering sunburn;
• the patient spends considerable time working or playing outdoors;
• the patient lives closer to the equator, at a high altitude, or in any location that gets intense, year-round sunshine; or
• the patient received therapeutic radiation treatments for adolescent acne.

Types of Skin Cancer
By far the most common type of skin cancer is basal-cell carcinoma. Fortunately, it is also the least dangerous kind: It tends to grow slowly, and it rarely spreads beyond its original site. Although basal-cell carcinoma is seldom life-threatening, if it is left untreated it can grow deep beneath the skin and into the underlying tissue and bone, causing serious damage—particularly if it is located near the eyes.

Squamous-cell carcinoma, the next most common type of skin cancer, frequently appears on the lips, face, or ears. It sometimes spreads to distant sites, including the lymph nodes and the internal organs. Squamous-cell carcinoma can become life threatening if it is not treated.

A third form of skin cancer, malignant melanoma, is the least common, but its incidence rate is increasing rapidly, especially in the Sunbelt states. Malignant melanoma is also the most dangerous type of skin cancer. If discovered early enough, it can be completely cured. If it is not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly.

Other Important Skin Growths
Two other common types of skin growths are moles and keratoses.

Moles are clusters of heavily pigmented skin cells; they may be flat or raised above the skin surface. While most pose no danger, some—particularly large moles that are present at birth, or those with mottled colors and poorly defined borders—may develop into malignant melanoma. Moles are frequently removed for aesthetic reasons, or because they’re constantly irritated by clothing or jewelry, which can sometimes cause precancerous changes.

Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun, and they sometimes develop into squamous-cell cancer.

Recognizing Skin Cancer
Basal- and squamous-cell carcinomas can vary widely in appearance. The cancer may begin as small white or pink nodules or bumps; it can be smooth and shiny, waxy, or pitted on the surface. Or it might appear as a red spot that is rough, dry, or scaly; a firm, red lump that may form a crust; a crusted group of nodules; a sore that bleeds or fails to heal after 2 to 4 weeks; or a white patch that looks like scar tissue.

Malignant melanoma is usually signaled by a change in the size, shape, or color of an existing mole, or as a new growth on normal skin. Watch for the “ABCD” warning signs of melanoma:

• asymmetry: a growth with unmatched halves;
• border irregularity: ragged or blurred edges;
• color: a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue; and
• diameter: a growth more than 6 mm across—about the size of a pencil eraser—or any unusual increase in size.

If all of these variables sound confusing, the most important thing to remember is that it is vital for patients to know their skin and examine it regularly, from the top of their heads to the soles of their feet—including their backs. If a patient notices any unusual changes on any part of the body, advise him or her to see a physician.

The Reimbursed Patient
As we know, patients typically start at the family physician’s office to have their skin examined, during an annual office visit or prompted by a specific health care concern. In other cases, patients may visit a dermatologist first. However, more and more often, patients come first to a plastic surgeon’s office. They may be coming to the plastic surgeon for a consultation that may ultimately result in skin-cancer detection. For this reason, it is important to make skin-cancer education part of every patient’s consultation.

We, as plastic surgeons, have the ability to help skin-cancer patients. We can surgically remove growths in a manner that maintains skin function and offers the most pleasing final appearance—a consideration that may be especially important if the cancer is on the face or other highly visible area. If a treatment other than surgical excision is called for, the plastic surgeon can refer patients to the appropriate specialist.

Often, I work with patients who have been referred to me by family physicians and dermatologists. In my office, treatment of skin-cancer patients has consisted of simple, straightforward procedures. Treating these patients also gives me the opportunity to present other solutions that my practice has to offer. Approximately 30% of my practice is reconstruction, and 10% of those patients convert to cash-pay procedures.

Because we can offer a potentially better outcome than a basic skin graft, it is important that we develop good working relationships with dermatologists. In this way, they can focus on treating the skin cancer and we can focus on correcting the defect. This is a simple step that demonstrates good will and creates the opportunity for more referrals.

Patients appreciate the benefits of dermatology treatment one day and defect closure the next day. And this combination usually produces a better outcome than a basic skin graft.

Diagnosis and Treatment
Skin cancer is diagnosed by removing all or part of the growth and examining its cells under a microscope. In many cases, the biopsy can be tricky. Some physicians may use their hospital lab for the analysis of the growth. Other physicians may outsource the removed growth to a local lab for biopsy.

The results of the biopsy may vary, depending upon numerous factors. For example, I saw one patient who went to a dermatologist to have a small portion of a growth on her shoulder removed for biopsy. However, the biopsy report gave conflicting results.

So the patient visited a plastic surgeon to have the growth completely removed. The plastic surgeon chose to send the removed growth to a hospital lab. In the end, the patient received a proper diagnosis through complete removal of the growth and hospital lab biopsy. This patient ultimately chose Mohs surgery to remove the cancer and reconstructive plastic surgery to correct the defect.

Of course, several methods are used to treat skin cancer. The type of treatment depends on the type of cancer, its stage of growth, and its location on the body.

Most skin cancers are removed surgically, by a plastic surgeon or a dermatologist. If the cancer is small, the procedure can be done quickly and easily, in an outpatient facility or the physician’s office, using local anesthesia. The procedure may be a simple excision, which usually leaves a thin, barely visible scar. Alternatively, curettage and desiccation may be performed. In this procedure, the cancer is scraped out with an electric current to control bleeding and to kill any remaining cancer cells. This leaves a slightly larger, white scar. In either case, the risks of the surgery are low.

If the cancer is large, however, or if it has spread to the lymph glands or elsewhere in the body, major surgery may be required. Other possible treatments for skin cancer include cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (applying anticancer drugs to the skin), and Mohs surgery (a special procedure in which the cancer is shaved off one layer at a time). Mohs surgery is performed only by specially trained physicians and often requires a reconstructive procedure as a follow-up.

Options for Treatment
All of the treatments mentioned above, when chosen carefully and appropriately, have good cure rates for most basal-cell and squamous-cell cancers—and even for malignant melanoma, if it is caught very early, before it has had a chance to spread.

Important patient considerations include a review of the various treatment options available, the possible effectiveness of the option for the patient’s particular type of cancer, the possible risks and side effects, the surgeon who can best perform the procedure, and the aesthetic and functional results that the patient can expect. Many patients today come to plastic surgeons’ offices for second opinions before they commit to a treatment.

The different techniques used for treating skin cancers can be life-saving, but they may leave a patient with less than pleasing aesthetic or functional results. Depending on the location and severity of the cancer, the consequences may range from a small but unsightly scar to permanent changes in facial structures such as the nose, ears, or lips.

In these cases, regardless of who performs the initial treatment, the plastic surgeon can be an important part of the treatment team. Reconstructive techniques—ranging from a simple scar revision to a complex transfer of tissue flaps from elsewhere on the body—can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and function.

Preventing a Recurrence
It is also important that patients have reasonable expectations when it comes to skin-cancer treatment. In the end, follow-up is crucial. Patients must reduce their risks of skin cancer by changing old habits and developing new ones. These preventive measures apply to people who have not had skin cancer as well. Patients can be advised to help themselves by taking the following precautions:

• Patients should avoid prolonged exposure to the sun, especially between 10 am and 2 pm, and especially during the summer months. Remember that UV rays pass right through water and clouds, and reflect from sand and snow.
• When patients do go out for an extended period of time, they must wear protective clothing, such as wide-brimmed hats and shirts with long-sleeves.
• On any exposed skin, patients must use a sunscreen with a sun-protection factor (SPF) of at least 15, and must reapply it frequently, especially after they have been swimming or perspiring.
• Finally, patients must examine their skin regularly. If they find anything suspicious, they must be advised to consult a plastic surgeon or a dermatologist as soon as possible.

Establishing good working relationships with dermatologists and selecting the right labs may be beneficial for you and your skin-cancer patients. In some cases, plastic surgery practices may receive the added benefit of being able to convert these patients to elective patients. But, whether we are considering converting dog-bite patients to facelift patients or finger-injury patients to regular photofacial patients, we have the ability to help produce better outcomes for some reimbursed patients.

Andrew T. Cohen, MD, is a board-certified plastic surgeon in private practice in Beverly Hills, Calif. He is on staff at Cedars-Sinai Medical Center in Los Angeles and Saint John’s Medical Center in Santa Monica, Calif. He can be reached via his Web site, www.andrewcohenmd.com.